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Neuropsychiatric Disease and Treatment 2012:8 585598
Neuropsychiatric Disease and Treatment
Psychogenic nonepileptic seizures: a treatment
review. What have we learned since the
beginning of the millennium?
Gaston Baslet
Department of Psychiatry, Brigham
and Womens Hospital, Harvard
Medical School, Boston, MA, USA
Correspondence: Gaston Baslet
Department of Psychiatry, Brigham
and Womens Hospital, 221 Longwood
Avenue, Boston, MA 02115, USA
Tel +1 617 732 4818
Fax +1 617 738 8703
Email gbaslet@partners.org
Abstract: Psychogenic nonepileptic seizures (PNES) can signicantly affect an individuals
quality of life, the health care system, and even society. The rst decade of the new millennium
has seen renewed interest in this condition, but etiological understanding and evidence-based
treatment availability remain limited. After the diagnosis of PNES is established, the rst thera-
peutic step includes a presentation of the diagnosis that facilitates engagement in treatment. The
purpose of this review is to present the current evidence of treatments for PNES published since
the year 2000 and to discuss further needs for clinical treatment implementation and research.
This article reviews clinical trials that have evaluated the efcacy of structured, standardized
psychotherapeutic and psychopharmacological interventions. The primary outcome measure
in clinical trials for PNES is event frequency, although it is questionable whether this is the
most accurate indicator of functional recovery. Cognitive behavioral therapy has evidence of
efcacy, including one pilot randomized, controlled trial where cognitive behavioral therapy
was compared with standard medical care. The antidepressant sertraline did not show a signi-
cant difference in event frequency change when compared to placebo in a pilot randomized,
double-blind, controlled trial, but it did show a signicant pre- versus posttreatment decrease
in the active arm. Other interventions that have shown efcacy in uncontrolled trials include
augmented psychodynamic interpersonal psychotherapy, group psychodynamic psychotherapy,
group psychoeducation, and the antidepressant venlafaxine. Larger clinical trials of these
promising treatments are necessary, while other psychotherapeutic interventions such as hypno-
therapy, mindfulness-based therapies, and eye movement desensitization and reprocessing may
deserve exploration. Flexible delivery of treatment that considers the heterogeneous backgrounds
of patients is emphasized as necessary for successful outcomes in clinical practice.
Keywords: conversion disorder, therapeutics, clinical trials, psychotherapeutic interventions,
psychopharmacological interventions
Introduction
Psychogenic nonepileptic seizures (PNES) are sudden, involuntary seizure-like attacks
that, unlike epileptic seizures, are not related to electrographic ictal discharges. PNES
presenting symptoms involve a wide array of nervous system functions, including
changes in behavior, motor activity, sensation, cognitive, and autonomic functions.
PNES can be initially mistaken as epileptic seizures, and an accurate diagnosis is
usually delayed by an average of 7 years.
1
Diagnosis is usually conrmed via video-
electroencephalography (v-EEG) monitoring in about a quarter of patients referred
to epilepsy referral centers.
2
There are no population-based studies to determine the
incidence of this disorder, but it has been estimated that 300,000400,000 people
may suffer from PNES in the United States alone.
3
PNES can greatly affect a patients
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quality of life
4,5
and are associated with high medical utiliza-
tion rates and hence also high personal and societal costs.
3

New evidence seems to indicate a higher premature mortality
rate in PNES subjects than that found in a comparison with
the Scottish general population, although deaths were not
seizure related.
6
Despite the recognition of this condition and its effect
on individuals, society, and the health care system, currently
there are signicant limitations in the etiological under-
standing of PNES. Traditionally, PNES have been linked to
a dysfunction in the processing of psychosocial stress.
7
A
conceptual framework has been proposed that explains PNES
as involuntary, stimulus-driven behavioral responses facili-
tated by an orienting tendency where cognitive, emotional,
and sensorimotor systems are not seemingly integrated.
8

This response tendency may take place because of a number
of vulnerability traits that increase a predisposition toward
PNES, including dissociative tendencies, alexithymia, cog-
nitive inexibility, and hypervigilance, to name a few.
8
This
conceptual framework remains hypothetical and highlights
the lack of a single etiological model that explains this
phenomenon.
9
Once PNES are properly diagnosed, treatment disposi-
tion usually includes a referral to mental health specialists.
10

Traditionally, mental health providers willing to work with
this population have utilized a variety of personalized psy-
chotherapeutic approaches that address specic psychiatric
comorbidities and hypothesized mechanisms.
11
This may
be necessary in part because of the heterogeneous psychi-
atric and medical backgrounds usually seen in the PNES
population.
12,13
Guidelines on how to treat this complex population
do not exist, owing to a lack of large, controlled trials
evaluating the efcacy of different treatment modalities.
14

In 2007 a Cochrane review looking at existing evidence-
based treatments for PNES showed an alarming lack of
randomized, controlled clinical trials with solid evidence
of efcacy.
15
According to a search of the PubMed database
conducted for the present article, there were no clinical trials
of specic interventions designed for PNES prior to 2000.
Some follow-up studies undertaken prior to 2000 indicate
that appropriate referral to mental health treatment had
positive therapeutic effects. For instance, a follow-up study
of 28 patients was published in 1999 and showed higher
rates of event freedom and improvement in patients who
received psychotherapy; however, the treatment delivered
was not standardized among participants.
16
A retrospective
analysis of 61 PNES patients demonstrated higher rates of
event freedom or reduction in those patients who received
either psychotherapy or feedback and routine neurological
care than in those who did not receive either. The psycho-
therapy treatment was provided either by a psychotherapist
from a comprehensive epilepsy center or by community
psychotherapists; no standardized treatment protocol is
described to be followed beyond the diagnosis presentation.
17

Remaining results consisted of isolated case reports for the
adult population.
18,19
The purpose of this review is to present the current
evidence of treatments for PNES published since the year
2000 and to discuss further needs for clinical treatment
implementation and research.
What do we know about other
PNES-related disorders?
PNES subjects share many underlying psychopathological
characteristics with other conversion and somatoform disorder
patients. It remains uncertain what determines the nal symp-
tomatic expression of PNES. One study comparing motor con-
version and PNES subjects found a higher incidence of adverse
childhood experiences and life events in the PNES group,
20

but it is far from clear if this constitutes a causative difference
between patients who may have loss of consciousness as one
of their manifestations, such as in PNES, and those with pure
motor manifestations. Post-traumatic stress disorder (PTSD),
other anxiety disorders, dissociative disorders, depression, and
borderline personality disorder are comorbidities frequently
encountered in PNES patients.
21
Given the overlap in psycho-
pathological structure with many of the disorders mentioned
here, it is relevant to briey review the current evidence of
effective treatments for these disorders.
The strongest evidence for other conversion disorders
comes from two randomized, controlled studies. In the rst
study, 20 patients with motor conversion symptoms received
weekly sessions of hypnotherapy and the patients change in
conversion symptoms and level of disability were compared
with a group of 24 subjects in a waiting list. Because the
semiology of the motor conversion symptoms was mixed, two
participants had PNES. Tremors, paresis, and gait complaints
were common. Motor conversion symptoms, rated by the
Video Rating Scale for Motor Conversion Symptoms, and
level of disability both showed larger post- versus pretreat-
ment improvement in the active group than in the control
group. Subjects did not receive other psychotherapy interven-
tions and there were no medication changes during the study,
although nearly half of the subjects were on psychotropic
medications at the onset of the trial.
22
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In the second randomized, controlled trial, conducted by
the same research group, 24 inpatients with motor conversion
symptoms received eight weekly hypnotherapy sessions and
were compared with 21 inpatients also with motor conver-
sion symptoms but who received a supportive individual
intervention instead during the admission. All subjects
received multidisciplinary group-centered psychotherapy
interventions and physical therapy. Eight subjects had PNES.
Both groups showed post- versus pretreatment reductions
in motor conversion symptoms and level of disability, with
hypnotherapy providing no additional effect.
23
Evidence-based treatment for other conversion disorders
has also been demonstrated by uncontrolled trials; particu-
larly, physical exercise
24
and psychodynamic psychotherapy
25

improve symptom severity in psychogenic movement disor-
ders. Antidepressant medication showed reduction and even
remission of psychogenic movements if the movements were
not accompanied by other somatoform disorders such as
hypochondriasis or somatization disorder.
26
Repetitive tran-
scranial magnetic stimulation over the motor cortex showed
improvement in 62 of 70 patients (89%) with psychogenic
paralysis, with total recovery observed in 53 (76%) of those
subjects, although this was a retrospective review instead
of a prospective trial.
27
Two of the studies mentioned earlier for conversion
disorder
22,23
included PNES subjects, but as these patients
were mixed with other conversion patients and represented
a minority of subjects within the studies, they were included
in this section instead of in the PNES-specific review
section.
Randomized, controlled trials of cognitive behavioral
therapy (CBT) in somatization and specic-symptom syn-
dromes (such as chronic fatigue syndrome, irritable bowel
syndrome, chronic pain) have supported the effective-
ness of this intervention.
28
Psychodynamic interpersonal
psychotherapy has also shown efcacy in irritable bowel
syndrome.
29,30
Antidepressants of various classes have also
demonstrated reduction in medically unexplained symptoms
including headache, bromyalgia, functional gastrointestinal
syndromes such as irritable bowel syndrome, idiopathic pain,
tinnitus, and chronic fatigue.
30,31
A review of the literature examining treatments for dis-
sociative disorders such as dissociative identity disorder,
depersonalization disorder, and dissociative disorder not
otherwise specied shows a lack of standardized and well-
designed studies.
32
One controlled single case study did show
improvement in dissociative pathology in a dissociative
identity disorder patient with cognitive analytic therapy.
33

No other controlled studies have been published for disso-
ciative disorders. It is possible that the need for long-term
outcome studies may limit the utility of short-term interven-
tions that can be adapted into a randomized, controlled trial
in this population.
32
A review of evidence-based treatments for other PNES-
related primary psychiatric disorders such as PTSD or border-
line personality disorder is beyond the scope of this review.
Nonetheless, it is noteworthy that there is mounting evidence
of effective structured psychotherapies, with the most exten-
sively studied psychotherapies being CBT for PTSD and
other anxiety disorders
34
and dialectical behavioral therapy
for borderline personality disorder,
35
although other forms
of psychotherapy (such as eye movement desensitization
and reprocessing [EMDR] in PTSD, or mentalization-based
therapy in borderline personality disorder) and psychophar-
macological interventions have also been investigated.
3539
Awareness of effective therapies in these conditions may
help customize treatment in PNES subjects with these fre-
quent comorbidities. From a research perspective, therapies
proven effective in these related pathologies may become
candidate interventions worth exploring in PNES.
Limitations in PNES clinical trials
A number of obstacles have been identied as contributing
to the difculty in conducting large clinical trials in PNES.
Some of these obstacles are intrinsic to PNES psychopa-
thology, such as the tendency to present in crises but reject
support when offered, emotional lability, and approach-
avoidance behavioral patterns. Other impairments are logisti-
cal in nature and include driving restrictions, other cognitive
and physical limitations related to medical and neurological
illnesses, and a wide range of comorbid neurologic and
psychiatric comorbidities, including epilepsy, which may
preclude enrollment based on the study.
40
The elds of neurology and psychiatry have played a role
in the lack of priority given to PNES treatment development.
Neurologists and emergency physicians tend to dismiss PNES
patients and may interpret the patients events as voluntary
fabrications. Psychiatrists and psychologists may not treat
PNES patients for fear of missing epilepsy when patients
have ongoing events.
41
As a result, PNES may be considered
an orphan disorder that neither eld wants to own as a
priority to develop therapeutic approaches for.
The lack of a single etiological model for PNES
9,14
limits
the selection of mechanism-specic interventions and hence
also limits outcome measures. However, a variety of proposed
etiological mechanisms (including avoidance, dissociation,
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Psychogenic nonepileptic seizure treatment review
personality structure, interpersonal factors, illness representa-
tion, biological vulnerabilities) may inform treatment choice
and selection of outcome measures.
9,42
Regardless of the etiological model that dictates the
intervention, useful outcome measures in PNES clinical tri-
als include event frequency or percentage of subjects who
achieved event freedom, psychopathological measures, social
and interpersonal functioning measures, medical utiliza-
tion rates, and quality of life.
9
Although event freedom is
usually the primary outcome in PNES clinical trials, it has
been established that the percentage of functional recovery
did not differ based on event remission 4.2 years after the
diagnosis.
43
Additionally, the relationship between PNES
frequency and health-related quality of life is inuenced by
psychopathological severity and other physical symptoms,
44

bringing to light the importance of these other measures that
are usually considered secondary.
Table 1 summarizes the factors enumerated here that
have implications in the development and conduction of
PNES clinical trials.
Presentation of the diagnosis: the
frst therapeutic intervention
After the diagnosis is conrmed, presenting the diagnosis
to the patient and, when appropriate, to his or her family,
becomes the rst therapeutic step toward recovery. Marked
reduction in health care demand after diagnosis presentation
has been established by prospective service evaluations.
45,46

For a subset of PNES individuals, awareness that they do
not suffer from epilepsy and that their events have emotional
underpinnings is sufcient for the episodes to be under con-
trol, at least for the subsequent 6 months.
47
Kanner et al
48

described this subgroup of patients with sustained control of
their attacks as having a lower degree of psychopathology
and the ability to recognize stressful events as precipitating
factors for their attacks.
How the PNES diagnosis is presented has always been con-
sidered a delicate matter, and protocols on how to present the
diagnosis have been suggested.
41,49
Although immediate relief
after diagnosis presentation has been documented,
50,51
mainte-
nance of such immediate improvement has been variable.
48,52

Because engagement in treatment will be crucial for recovery,
and because PNES subjects are known to have low rates of
treatment retention,
53,54
this rst therapeutic step is a decisive
moment that may dene the patients clinical and functional
outcome and hence it should be handled carefully.
A standardized protocol for diagnosis presentation was
used in 50 newly diagnosed PNES subjects in a multicenter
study. The protocol covered 14 points addressing all domains
of patients illness representations and it was found to be
acceptable to patients. Fourteen percent at 2 weeks after the
diagnosis and 20% at 11 weeks after the diagnosis reported
attack freedom or only occasional events.
55
Not uncommonly, health professionals may misinterpret
the psychogenic origin of these events as a sign of volun-
tary fabrication. Understanding PNES as faked seizures
may generate a negative attitude toward patients, and it can
behaviorally reinforce reluctance in the patient to accept the
diagnosis. Although there is no neurobiological evidence
for PNES at this juncture, it is known from functional neu-
roimaging studies in psychogenic tremor and psychogenic
paralysis
5658
that brain activation differs between feigned
and psychogenic symptoms, lending support to the brain
basis of the disorder.
Table 2 summarizes the key points for a successful presen-
tation of the diagnosis based on previous recommendations
49,55

and the authors own clinical experience at a nonepileptic
seizure intervention clinic previously held at the University
of Illinois Medical Center at Chicago.
PNES: renewed interest?
The rst decade of the new millennium has seen an increase
in interest in PNES. A limited search of the PubMed database
for articles utilizing terms related to PNES in the title or
abstract showed there were 96 articles published on the topic
during the 1980s, 243 articles published during the 1990s,
and 426 articles published during the 2000s. This growing
interest in the topic has propelled a renewed enthusiasm in
Table 1 Limitations in the conduction of psychogenic nonepileptic
seizures (PNES) clinical trials
9,14,4042
Limitations
Obstacles intrinsic to PNES psychopathology
Emotional lability
Approach-avoidance behavioral patterns
Tendency to present in crisis and reject support
Lack of motivation (due to depression, reinforcing factors)
Logistical impairments preventing participation in treatment and/or
enrollment in research
Driving restrictions
Cognitive limitations (due to intellectual disability, cognitive
impairment due to neurological illness, cogniform symptoms)
Physical limitations (due to pain, physical disabilities from neurological,
medical, or conversion symptoms)
Severity of psychopathology that may limit enrollment in studies
(suicidality, psychosis, severe depression)
Relative lack of disease ownership by medical specialty
Lack of understanding of a single etiological mechanism
Unclear utility of various outcome measures
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identifying treatment interventions for this population. The
following section will review treatment studies that have been
published since the year 2000.
Treatment review
Methods
A PubMed literature search was conducted, focusing on treat-
ment studies on PNES from January 2000 through December
2011. The search included articles with the terms nonepileptic
seizures (as well as non-epileptic seizures), psychogenic
seizures, dissociative seizures, conversion seizures,
pseudoseizures, psychogenic spells, and psychogenic
attacks in the title or abstract. The results of these searches
were combined with the Medical Subject Headings term
therapeutics. Titles and abstracts were reviewed to identify
potentially relevant articles, which were then retrieved to
review the full article. All results were limited to English-
language articles and a study was included if it recruited all
adult PNES patients only. The intervention being investigated
had to be described as being delivered as uniformly as possible
to all subjects. Case reports and case series were excluded.
The main aspects of these studies are summarized in Table 3.
Results: psychotherapeutic interventions
CBT
CBT is based on the concept that dysfunctional conditioned
responses and thought processes lead to a misperception
of reality that presents as psychopathological symptoms.
14

In the case of CBT, PNES are conceptualized as dissocia-
tive responses to arousal when a patient is confronted with
stimuli or circumstances that the patient tends to avoid, either
consciously or not.
59
CBT is the only psychotherapeutic intervention studied in
PNES in a pilot randomized, controlled trial
60
and it is there-
fore the psychotherapeutic treatment with the highest level of
efcacy evidence (Class III) in this population. The content
of Goldstein et als
59,60
CBT approach emphasizes the fol-
lowing concepts in different stages through twelve outpatient
sessions: (1) engagement in treatment; (2) reinforcement of
independence; (3) distraction, relaxation, and refocusing tech-
niques at the earliest signs of an event; (4) graded exposure to
avoided situations; (5) cognitive restructuring; and (6) relapse
prevention. In Goldstein et als
60
randomized, controlled
trial, both the active and control groups received standard
medical care (SMC) treatment, comprising up to seven
neuropsychiatric appointments that focused on psychoeduca-
tion, support measures, and antiepileptic drug withdrawal.
Event frequency was not different between analyzed groups
(CBT + SMC, n = 33; SMC [control], n = 31) at the start
of treatment (CBT + SMC group median, twelve events per
month; SMC group median, eight events per month), but
signicantly lower frequency for the CBT group at the end
of the 12-session treatment (SMC group median, 6.75 events
per month; CBT + SMC group median, two events per month)
(P = 0.002), with a large between-group effect size (0.75). At
the 6-month follow-up, the between-group effect size (SMC
group median, ve events per month; CBT + SMC group
median, 1.5 events per month) was medium (0.42) and not
statistically signicant (P = 0.082). Therapist contact was
greater in the active group, and this level of contact was not
controlled for in the control group, which may explain the
Table 2 Psychogenic nonepileptic seizures (PNES): how should
the diagnosis be presented?
Presentation Description
Multidisciplinary
presentation
The neurologist making the diagnosis and the
mental health professional who will follow the
patient are physically present when the diagnosis
is revealed and discussed, and they both agree
on the treatment plan
Objective discussion
of fndings
Description of the event as observed during
video recording and the lack of ictal discharges,
ruling out an epileptic etiology
Providers believe
the diagnosis
Emphasis that the attacks are still considered
real and out of the patients control
Explanation of the
psychogenic nature
of the attacks
An individualized hypothetical explanation is given
on how these episodes may be taking place
Examples of trait vulnerabilities are highlighted
Patients may also be presented with examples of
different forms of psychopathology (especially one
they do not suffer from) to help them understand
that other signs and symptoms in psychiatric
disorders may be perceived as involuntary as well
The explanation may include discussion about
the patients brain managing certain stressful
situations in a particular manner
Psychotherapy
referral
Psychotherapeutic interventions are introduced
as an opportunity to learn new ways of relating
to physical and emotional experiences, reducing
vulnerability toward PNES, not as a promise to
eradicate PNES for life
When appropriate, redefnition of family
involvement is discussed
Psychiatric
comorbidities
Emphasis is placed on the treatment of psychiatric
comorbidities with both psychopharmacological
and psychotherapeutic interventions
Involvement of
neurologist post
diagnosis
Neurologists should remain involved and
available and work collaboratively with mental
health professionals to facilitate antiepileptic drug
withdrawal, treatment of comorbid neurological
conditions (including epilepsy), ongoing
evaluation should new events or symptoms arise,
and overall monitoring of the patients outcome
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Table 3 Treatment trials conducted in psychogenic nonepileptic seizures (PNES)
Reference Methods Results Comments
Trial design Intervention Final analysis (n) Dependent variables Data collection method
Goldstein et al
60
Randomized, controlled CBT arm: 12 weekly or
fortnightly hour-long sessions
SMC (both arms): supportive
sessions with psychoeducation
and AED withdrawal
64 Monthly event frequency, rate of
event freedom, Work and Social
Adjustment Scale, Hospital Anxiety
and Depression Scale, modifed
Client Service Receipt Inventory
Data collected at start of treatment, end
of treatment, and at 6-month follow-up
Signifcantly lower event frequency at treatment
end and a trend for lower event frequency
at 6-month follow-up following CBT
Large between-group effect size at end of
treatment and medium effect size at follow-up
No difference between groups in secondary
measures
SMC group not controlled for therapist
contact (which was greater in CBT)
Nature of treatment precludes blinding from
SMC provider
Selection bias in favor of chronic, more
diffcult-to-treat patients
Willingness to enroll in study might have
infuenced favorable outcome in SMC group
6-month follow-up period too short for
change in employment status
LaFrance et al
61
Open-label, prospective,
uncontrolled
12 weekly hour-long
CBT sessions
20 Weekly event frequency, BDI,
Modifed HDRS, Davidson Trauma
Scale, DES, BIS, Family Assessment
Device, SCL-90, Oxford Handicapped
Scale, Ways of Coping, QOLIE-31
Event frequency obtained for the week
prior to enrollment, after enrollment,
weekly during treatment, and at completion
Measures were obtained at baseline,
during treatment, and after treatment
Mean event frequency decreased signifcantly
from week 1 through end of treatment
Most scales assessing secondary outcome
measures showed signifcant improvement from
baseline to fnal session (except HDRS and DES)
Only individuals with v-EEG diagnosed PNES
were included
Article states follow-up questionnaires were
administered at months 4, 8, and 12 from the
date of enrollment (although data not available)
Kuyk et al
62
uncontrolled
Inpatient individualized
CBT-based treatment for
26 months (average,
4.8 months)
22 Average weekly event frequency,
SCL-90, BDI, State-Trait Inventory,
Utrecht Coping List, SF-36,
Dissociation Questionnaire
Average weekly event frequency for
previous 3 weeks at onset and end
of treatment; average weekly event
frequency for previous 4 weeks at
6-month follow-up
Secondary measures also obtained
at onset of treatment, discharge, and
6-month follow-up
Signifcant decrease in event frequency from
onset to discharge, from discharge to follow-up,
and from onset to follow-up
27.3% achieved event freedom at end
of treatment and 44% at follow-up
Signifcant decrease in BDI, State-Trait Inventory,
dissociation questionnaire, and Utrecht Coping
List from onset to discharge and in all measures
from onset to follow-up
Diagnosis confrmed via EEG; comorbid
epilepsy subjects excluded from analysis
Inpatient setting not controlled for
Treatment was individualized, limiting
generalizability of results
Sample selection bias toward patients with
less severe psychiatric comorbidities, as this
was an exclusion criterion for participation
Mayor et al
64
Retrospective,
naturalistic study,
uncontrolled
Up to 20 sessions of brief
augmented psychodynamic
interpersonal therapy
47 Monthly event frequency,
SF-36, PHQ-15
Questionnaire data collected 50 months
(median) after baseline measures and
42 months (median) after end of
treatment
Psychosocial functioning measures
obtained at baseline
At follow-up (median, 42 months after end of
treatment), 25.5% of patients had become
event free; a further 40.4% achieved an
event reduction of .50%
Health care utilization declined signifcantly
from baseline to follow-up, based on
questionnaire
Some patients did not obtain PNES diagnosis
with v-EEG
Contact with other providers and
antidepressant treatment may have
infuenced outcomes
No predefned time point after therapy
Measurements of social functioning only
obtained at baseline, not at follow-up
Barry et al
66
uncontrolled
32 weekly 90-minute group
psychodynamic
psychotherapy sessions
7 Weekly event frequency,
BDI, SCL-90
Data collected at start of treatment,
weekly for event frequency, and at
16 and 32 weeks for secondary measures
Six of seven patients with decrease in event
frequency over course of treatment
Four of seven with event cessation
Five subjects remained event free several
months after treatment
Signifcant reduction in BDI over the course
of treatment
Meaningful changes in ten of twelve SCL-90
subscales
Five patients receiving individual
psychotherapy concurrently, one with new
antidepressant
Prigatano et al
67
uncontrolled
24 weekly 90-minute
group psychoeducational
interventions
9 Weekly event frequency, MMPI-2,
and neurocognitive measures
(WAIS-III, CVLT, or RAVLT)
Weekly event log; weekly quiz
about previous session
MMPI-2 and neurocognitive evaluation
obtained during assessment period
Six patients reported a decrease in event
frequency, two reported no change,
and one reported an increase
Signifcant correlation between MMPI-2
paranoid scale and frequency of events (positive)
and correct answers in quiz (negative)
Typical conversion V profle observed
Two series of six and seven patients each;
frst series with no exclusion criteria; second
series required pretreatment interview
One patient had comorbid epilepsy
Zaroff et al
68
uncontrolled
10 weekly hour-long
interventions
7 Pre- and posttreatment event
frequency, Coping Inventory
for Stressful Situations, Davidson
Trauma Scale, Curious Experiences
Survey, STAXI-2, QOLIE-31
Pre- and posttreatment administration
of all measures
Pretreatment questionnaire scores
were compared with normative data
(except event frequency) and with
posttreatment score
No change in event frequency in four subjects
(three had achieved remission at treatment
initiation), a decrease in two subjects, and an
increase in one subject
Signifcant reduction in Curious Experience Survey,
Davidson Trauma Scale, and Coping Inventory for
Stressful Situations (Emotion Subscale), and STAXI-2
Anger Expression Index Score
Increase in QOLIE-31
All had v-EEG-confrmed diagnosis
Three of seven subjects had event freedom
at treatment initiation
(Continued)
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Table 3 Treatment trials conducted in psychogenic nonepileptic seizures (PNES)
Goldstein et al
60
Randomized, controlled CBT arm: 12 weekly or
fortnightly hour-long sessions
SMC (both arms): supportive
sessions with psychoeducation
and AED withdrawal
64 Monthly event frequency, rate of
event freedom, Work and Social
Adjustment Scale, Hospital Anxiety
and Depression Scale, modifed
Client Service Receipt Inventory
Data collected at start of treatment, end
of treatment, and at 6-month follow-up
Signifcantly lower event frequency at treatment
end and a trend for lower event frequency
at 6-month follow-up following CBT
Large between-group effect size at end of
treatment and medium effect size at follow-up
measures
SMC group not controlled for therapist
contact (which was greater in CBT)
Nature of treatment precludes blinding from
SMC provider
Selection bias in favor of chronic, more
diffcult-to-treat patients
Willingness to enroll in study might have
infuenced favorable outcome in SMC group
6-month follow-up period too short for
change in employment status
LaFrance et al
61
uncontrolled
12 weekly hour-long
CBT sessions
20 Weekly event frequency, BDI,
Device, SCL-90, Oxford Handicapped
Scale, Ways of Coping, QOLIE-31
Event frequency obtained for the week
prior to enrollment, after enrollment,
weekly during treatment, and at completion
Measures were obtained at baseline,
during treatment, and after treatment
Mean event frequency decreased signifcantly
from week 1 through end of treatment
Most scales assessing secondary outcome
measures showed signifcant improvement from
baseline to fnal session (except HDRS and DES)
Only individuals with v-EEG diagnosed PNES
were included
Article states follow-up questionnaires were
administered at months 4, 8, and 12 from the
date of enrollment (although data not available)
Kuyk et al
62
uncontrolled
Inpatient individualized
CBT-based treatment for
26 months (average,
4.8 months)
22 Average weekly event frequency,
SCL-90, BDI, State-Trait Inventory,
Utrecht Coping List, SF-36,
Dissociation Questionnaire
Average weekly event frequency for
previous 3 weeks at onset and end
of treatment; average weekly event
frequency for previous 4 weeks at
6-month follow-up
Secondary measures also obtained
at onset of treatment, discharge, and
6-month follow-up
Signifcant decrease in event frequency from
onset to discharge, from discharge to follow-up,
and from onset to follow-up
27.3% achieved event freedom at end
of treatment and 44% at follow-up
Signifcant decrease in BDI, State-Trait Inventory,
dissociation questionnaire, and Utrecht Coping
List from onset to discharge and in all measures
from onset to follow-up
Diagnosis confrmed via EEG; comorbid
epilepsy subjects excluded from analysis
Inpatient setting not controlled for
Treatment was individualized, limiting
generalizability of results
Sample selection bias toward patients with
less severe psychiatric comorbidities, as this
was an exclusion criterion for participation
Mayor et al
64
Retrospective,
naturalistic study,
uncontrolled
Up to 20 sessions of brief
augmented psychodynamic
interpersonal therapy
47 Monthly event frequency,
SF-36, PHQ-15
Questionnaire data collected 50 months
(median) after baseline measures and
42 months (median) after end of
treatment
Psychosocial functioning measures
obtained at baseline
At follow-up (median, 42 months after end of
treatment), 25.5% of patients had become
event free; a further 40.4% achieved an
event reduction of .50%
Health care utilization declined signifcantly
from baseline to follow-up, based on
questionnaire
Some patients did not obtain PNES diagnosis
with v-EEG
Contact with other providers and
antidepressant treatment may have
infuenced outcomes
No predefned time point after therapy
Measurements of social functioning only
obtained at baseline, not at follow-up
Barry et al
66
uncontrolled
32 weekly 90-minute group
psychodynamic
psychotherapy sessions
7 Weekly event frequency,
BDI, SCL-90
Data collected at start of treatment,
weekly for event frequency, and at
16 and 32 weeks for secondary measures
Six of seven patients with decrease in event
frequency over course of treatment
Four of seven with event cessation
Five subjects remained event free several
months after treatment
Signifcant reduction in BDI over the course
of treatment
Meaningful changes in ten of twelve SCL-90
subscales
Five patients receiving individual
psychotherapy concurrently, one with new
antidepressant
Prigatano et al
67
uncontrolled
24 weekly 90-minute
interventions
9 Weekly event frequency, MMPI-2,
and neurocognitive measures
(WAIS-III, CVLT, or RAVLT)
Weekly event log; weekly quiz
about previous session
MMPI-2 and neurocognitive evaluation
obtained during assessment period
Six patients reported a decrease in event
frequency, two reported no change,
and one reported an increase
Signifcant correlation between MMPI-2
paranoid scale and frequency of events (positive)
and correct answers in quiz (negative)
Typical conversion V profle observed
Two series of six and seven patients each;
frst series with no exclusion criteria; second
series required pretreatment interview
One patient had comorbid epilepsy
Zaroff et al
68
uncontrolled
10 weekly hour-long
interventions
7 Pre- and posttreatment event
frequency, Coping Inventory
for Stressful Situations, Davidson
Trauma Scale, Curious Experiences
Survey, STAXI-2, QOLIE-31
Pre- and posttreatment administration
of all measures
Pretreatment questionnaire scores
were compared with normative data
(except event frequency) and with
posttreatment score
No change in event frequency in four subjects
(three had achieved remission at treatment
initiation), a decrease in two subjects, and an
increase in one subject
Signifcant reduction in Curious Experience Survey,
Davidson Trauma Scale, and Coping Inventory for
Stressful Situations (Emotion Subscale), and STAXI-2
Anger Expression Index Score
Increase in QOLIE-31
All had v-EEG-confrmed diagnosis
Three of seven subjects had event freedom
at treatment initiation
(Continued)
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Table 3 (Continued)
LaFrance et al
69
Randomized,
double-blind,
placebo-controlled
Sertraline 25200 mg daily
versus placebo
33 Fortnightly event frequency, BDI,
Device, SCL-90, GAF, Oxford
Handicapped Scale, Ways of
Coping, QOLIE-31
Initial visit: SCID-I and pretreatment 2-week
event frequency and baseline measures
Follow-up visit 2 weeks later with
initiation of blinded treatment, biweekly
visits for 12 weeks with measurement
of event frequency
All measures and 2-week event
frequency at week 12
No difference between treatment groups
regarding event frequency by risk ratios
Relative change in biweekly event frequency from
baseline to study end, separately, by treatment
group with 45% decrease in the sertraline group
versus 8% increase in the placebo group
measures
Not powered for establishing treatment
effcacy because of limited sample size
Study not stratifed to differentiate based
on presence of personality disorders
Pintor et al
70
uncontrolled
All subjects with
depressive and/or
anxiety disorder
Venlafaxine 75300 mg daily
by clinician criteria
19 Monthly event frequency, HDRS,
HARS, Hospital Anxiety and
Depression Scale
Initial visit: SCID-I and washout for
15 days, if necessary
Follow-up visit 15 days later with initiation
of venlafaxine treatment, monthly visits
for 5 months with measurement with
standardized scales (except SCID-I)
Statistically signifcant reduction in all variables
(including event frequency and depression and
anxiety scales)
No difference in patients with more than
ten events in 15 days
Inclusion in study within 12 months of
diagnosis (rather than a year)
No direct effcacy outcomes on conversion
symptoms in absence of affective or anxiety
symptoms
No measurement of side effects
Abbreviations: AED, antiepileptic drug; BDI, Beck Depression Inventory; BIS, Barrett Impulsivity Scale; CBT, cognitive behavioral therapy; CVLT, California Verbal
Learning Test; DES, Dissociative Experiences Scale; EEG, electroencephalography; GAF, Global Assessment of Functioning; HARS, Hamilton Anxiety Rating Scale; HDRS,
Hamilton Depression Rating Scale; MMPI-2, Minnesota Multiphasic Personality Inventory 2; PHQ-15, Patient Health Questionnaire 15-Item Somatic Symptom Severity
Scale; QOLIE-31, Quality of Life in Epilepsy Inventory 31; RAVLT, Rey Auditory Verbal Learning Test; SCID-I, Structured Clinical Interview for DSM-IV Axis I Disorders;
SCL-90, Symptoms Checklist-90; SF-36, 36-Item Short Form Health Survey; SMC, standard medical care; STAXI-2, State-Trait Anger Expression Inventory-2; v-EEG, video-
electroencephalography; WAIS-III, Wechsler Adult Intelligence Scale-III.
decrease in between-group difference over time. At the same
time, willingness to enroll in this study may have inuenced
the control groups reduction in events.
LaFrance et als
61
uncontrolled CBT study had 20 subjects
enrolled and 17 completed a 12-week outpatient CBT protocol.
The protocol was driven by similar principles as those of or
Goldstein et als study,
60
but it specically followed a manual
that focused on several points including mood-cognition-
environment connections; identication of moods, situations,
and thoughts; relaxation techniques; healthy communication;
and examination of internal and external triggers. Mean event
frequency decreased signicantly from week 1 (mean event
frequency, 17.2 per week) through the end of treatment (mean
event frequency, 7.1 per week) (P = 0.001). Eleven of the 17
subjects completing the study (65%) reported no events per
week during the nal CBT session. Mean scores on measures
of depression, anxiety, somatic symptoms, quality of life, and
psychosocial functioning showed signicant improvement
from baseline to the end of treatment. The study does not con-
tain follow-up data beyond week 12, motivating future trials to
examine if these strong results can be maintained over time.
An uncontrolled, prospective inpatient treatment program
based on CBT principles has also provided evidence of reduc-
tion of seizure-like events.
62
The treatment was provided over a
prolonged inpatient admission, that allowed home visits during
weekends, with a 4-week psychological diagnostic process,
followed by a multidisciplinary treatment aimed at cognitive
restructuring, trauma treatment, stimulus differentiation, cop-
ing skills training, stress management, behavioral analysis,
and rational emotive therapy, all provided in individual and/or
group settings. Family interventions were also included. The
duration of the program ranged from 2 to 6 months, with an
average duration of 4.8 months. The 22 completers showed a
signicant reduction between treatment initiation (mean event
frequency, 6.6 per week) and end of treatment (mean event
frequency, 3.0 per week) (P = 0.02) and 16 of them showed
a signicant reduction between treatment initiation and the
6-month follow-up after discharge (mean event frequency, 0.9
per week) (P = 0.002). Reductions between initiation of treat-
ment and the 6-month follow-up period were also observed in
measures of depression, anxiety, dissociation, health-related
quality of life, and overall psychopathology. Six months after
discharge, 80% of 16 patients had an event reduction of over
50% and half of these patients were event free. The prolonged
inpatient setting where the treatment took place and the incor-
poration of several treatment strategies may have contributed to
these positive results. At the same time, the multimodal nature
of the treatment and the setting where it took place may repre-
sent limitations when it comes to adoption of this therapeutic
approach for most PNES patients. Willingness to be admitted
to an inpatient unit for over 2 months may represent a selection
bias toward patients already open to the diagnosis.
Psychodynamic psychotherapies: augmented
psychodynamic interpersonal therapy
and group psychodynamic psychotherapy
According to psychodynamic theory, symptoms and behav-
iors are presumed to be inuenced by internal processes,
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Table 3 (Continued)
LaFrance et al
69
Randomized,
double-blind,
placebo-controlled
Sertraline 25200 mg daily
versus placebo
33 Fortnightly event frequency, BDI,
Device, SCL-90, GAF, Oxford
Handicapped Scale, Ways of
Coping, QOLIE-31
Initial visit: SCID-I and pretreatment 2-week
event frequency and baseline measures
Follow-up visit 2 weeks later with
initiation of blinded treatment, biweekly
visits for 12 weeks with measurement
of event frequency
All measures and 2-week event
frequency at week 12
No difference between treatment groups
regarding event frequency by risk ratios
Relative change in biweekly event frequency from
baseline to study end, separately, by treatment
group with 45% decrease in the sertraline group
versus 8% increase in the placebo group
measures
Not powered for establishing treatment
effcacy because of limited sample size
Study not stratifed to differentiate based
on presence of personality disorders
Pintor et al
70
uncontrolled
All subjects with
depressive and/or
anxiety disorder
Venlafaxine 75300 mg daily
by clinician criteria
19 Monthly event frequency, HDRS,
HARS, Hospital Anxiety and
Depression Scale
Initial visit: SCID-I and washout for
15 days, if necessary
Follow-up visit 15 days later with initiation
of venlafaxine treatment, monthly visits
for 5 months with measurement with
standardized scales (except SCID-I)
Statistically signifcant reduction in all variables
(including event frequency and depression and
anxiety scales)
No difference in patients with more than
ten events in 15 days
Inclusion in study within 12 months of
diagnosis (rather than a year)
No direct effcacy outcomes on conversion
symptoms in absence of affective or anxiety
symptoms
No measurement of side effects
Abbreviations: AED, antiepileptic drug; BDI, Beck Depression Inventory; BIS, Barrett Impulsivity Scale; CBT, cognitive behavioral therapy; CVLT, California Verbal
Learning Test; DES, Dissociative Experiences Scale; EEG, electroencephalography; GAF, Global Assessment of Functioning; HARS, Hamilton Anxiety Rating Scale; HDRS,
Hamilton Depression Rating Scale; MMPI-2, Minnesota Multiphasic Personality Inventory 2; PHQ-15, Patient Health Questionnaire 15-Item Somatic Symptom Severity
Scale; QOLIE-31, Quality of Life in Epilepsy Inventory 31; RAVLT, Rey Auditory Verbal Learning Test; SCID-I, Structured Clinical Interview for DSM-IV Axis I Disorders;
SCL-90, Symptoms Checklist-90; SF-36, 36-Item Short Form Health Survey; SMC, standard medical care; STAXI-2, State-Trait Anger Expression Inventory-2; v-EEG, video-
electroencephalography; WAIS-III, Wechsler Adult Intelligence Scale-III.
many times unconscious to the patient, with childhood
experiences being highly inuential to the development
of persistent maladaptive behavioral patterns.
14
Defense
mechanisms such as dissociation and somatization are used
to split traumatic memories from consciousness.
63
The goal
of psychodynamic therapy is to increase the patients aware-
ness of these patterns to facilitate change.
14
Mayor et al
64
studied brief augmented psychodynamic
psychotherapy in 47 PNES subjects.
64
Key features from
this kind of psychotherapy include the assumption that the
patients problems are linked to difculties in his or her
personal relationships, which are explained by interpersonal
patterns developed earlier in life. The therapeutic mechanism
of this approach is based on the identication and change of
unhelpful interpersonal patterns and the more effective pro-
cessing of emotions related to both present and past issues.
Techniques from somatic trauma therapy, such as control of
autonomic arousal, tracking of somatic symptoms, linkage
to emotional triggers, and processing of traumatic memories,
are used to augment the psychodynamic interpersonal
approach.
65
The 47 subjects completed up to 20 weekly or
fortnightly sessions (range, one to eighteen sessions; median,
ve sessions); twelve of these subjects (26%) achieved event
freedom 42 months (median) after the conclusion of therapy
and a further 19 subjects (40%) reported more than 50%
reduction in event frequency compared with baseline. The
median frequency of events per month decreased from six
at baseline to one at follow-up (P , 0.007). There was also
a signicant decline in health care utilization at follow-up.
Some of these patients had not obtained the diagnosis of
PNES through v-EEG conrmation, relying on clinical
impression by a neurologist with expertise in epilepsy, direct
observation of the events in clinic, video recordings, or a
history or witness account suggestive of PNES. Contact
with other providers, such as a neurologist, or prescription of
antidepressant or anxiolytic medication may have inuenced
improvement as well.
A few studies have evaluated group psychotherapy in
the treatment of PNES. Barry et al
66
reported on the ef-
cacy of a 32-week-long psychodynamically oriented group
psychotherapy, which had as a goal the conscious and
verbal expression of emotional distress, obviating the need
for somatic displays of stress. Development of assertive
coping strategies instead of passive avoidant behavior was
emphasized. Six of the seven (86%) completers experienced
a decrease in frequency of events over the treatment period.
Four of the seven (57%) achieved complete remission, with
very occasional recurrence in the face of emotional distress.
Depression severity and overall severity of psychopathology
also showed improvement.
Other group interventions
Prigatano et al
67
reported a decrease in six of nine subjects
(67%) with PNES during completion of a 6-month group
psychotherapy program. The treatment consisted of 24
90-minute sessions that reviewed facts about epilepsy and
PNES and where discussion of feelings that may relate to
past or present events relevant to PNES was encouraged.
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Results were based on a comparison between number of
events during the rst twelve sessions and number of events
during the second twelve sessions.
Zaroff et al
68
reported on the efcacy of a 1-hour weekly
group psychotherapy intervention over the course of 10 weeks.
The approach was psychoeducational in nature and it covered
topics including PNES, anger, trauma and abuse, somatization
tendencies, quality of life, and stress management techniques,
among others. Four of the seven completers (57%) who were
enrolled in this program experienced no change in event fre-
quency, but in three of these four subjects (75%), event ces-
sation had been achieved at treatment initiation. Two subjects
experienced a decrease and one an increase in event frequency.
Decreases were seen in post-traumatic and dissociative
symptoms and emotionally based coping mechanisms. The
report does not mention if patients also received additional
individual psychotherapy or psychopharmacotherapy during
the group intervention.
Results: psychopharmacological
interventions
The lack of a consistent neurobiological model in PNES
makes identication of a customized neurochemical inter-
vention unrealistic at this stage. However, under the premise
that difculties with impulsivity, compulsive tendencies,
depression, and anxiety are associated with serotonergic
decits and these conditions are usually seen comorbidly
in PNES,
14
serotonin reuptake inhibitors, both selective
and dual action, have been investigated as potentially use-
ful compounds.
LaFrance et al
69
conducted a randomized, double-blind,
placebo-controlled trial evaluating the efcacy of exible-
dose sertraline over 12 weeks at reducing PNES frequency
and improving other psychiatric severity and psychosocial
measures. The nal analysis included 33 subjects with one
or more events in the 2 weeks prior to enrollment. Patients
were allowed to participate if taking other antidepressants,
except for monoamine oxidase inhibitors and sertraline at a
100 mg/day or higher dose for more than 30 days. Dose of the
concurrent antidepressants, if prescribed, was held constant.
There was no difference between groups in fortnightly event
frequency change (risk ratio, 0.51; P = 0.29). However, when
groups were analyzed separately, the sertraline arm showed a
45% decrease in biweekly event frequency (P = 0.03), while
the control group showed an 8% increase (P = 0.78). There
were no between-arm differences in secondary outcome
measure changes. The limited sample size means this well-
conducted study is not powered enough to establish treatment
efcacy. The sertraline group had a higher rate of baseline
event frequency in those subjects with Axis II disorders than
in those without Axis II disorders; this baseline difference
was not observed in the control group. The study was not
stratied to differentiate results based on the presence of
personality disorders.
An open-label, prospective, uncontrolled study of
exible-dose venlafaxine evaluated event reduction as well
as anxiety and depression severity.
70
All enrolled subjects
had v-EEG-conrmed PNES but also had to meet criteria
for a unipolar depressive disorder and/or anxiety disorder.
Subjects underwent monthly assessments for 5 months. The
19 subjects who completed the study showed a statistically
signicant reduction in all symptom scales and monthly
event frequency at the fth-month assessment compared
with the initial assessment. There was no difference in
patients with more than ten events in the 15-day baseline
pre-inclusion assessment period. That the inclusion of
PNES subjects after diagnosis was conrmed no earlier
than 2 months from enrollment may have assisted in the
attention provided to the diagnosis; however, this may be
irrelevant, as the mean duration of PNES was 6 years in
this study.
Discussion and future directions
One pilot psychopharmacotherapeutic study meeting criteria
for Class II evidence
69
and one pilot psychotherapeutic study
meeting criteria for Class III evidence
60
are the scientically
strongest evidence currently available for the treatment of
PNES.
71
Both studies had limited power, and while strong
support cannot be claimed for these interventions at this
point, it is appropriate to say that these are very promising
approaches that require further study. This limited evidence
shows how early the current stage is in the development of
therapeutic interventions for this clinical entity. The lack of
a clear-cut etiological model that supports the psychogenic
origin of PNES, and the heterogeneous background that can
lead to a similar phenotypic presentation, can make nd-
ing an explanation for the disorder and a one-size-ts-all
intervention a difcult task to achieve. On the other hand,
the eld of psychiatry is known to accommodate etiologi-
cal uncertainties and a wide variety of risk factors that can
lead to a specic symptom display while still investing
in the development of treatment interventions. Why are
PNES lagging behind then in treatment development? Is
the fact that many of these patients are initially thought to
have epilepsy a reason for this cold embrace and, to some
degree, skepticism?
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Baslet
Because most PNES patients enter diagnosis and
treatment through the epilepsy door, the collaboration
between neurology and psychiatry is of utmost relevance.
Dual training or neuropsychiatric specialization may help
bridge this dichotomy, although there may be a limited
number of professionals with such background and inter-
est. Treatment as usual for PNES mostly depends on a
referral to a mental health professional.
10
For individuals
who accept the diagnosis without hesitation, who do not
possess chronic risk factors that perpetuate their symp-
toms, and who are able to nd a competent professional
comfortable treating PNES, treatment as usual may
prove therapeutic. However, for many patients, limited
acceptance of the diagnosis, a number of chronic psychi-
atric difculties, and limited therapeutic resources still
represent barriers to adequate treatment that can lead to a
successful outcome.
A multidisciplinary and exible model for the treatment
of PNES may provide the background infrastructure neces-
sary upon which the specic psychiatric interventions may
be deployed successfully. Beyond the development of this
infrastructure, understanding the vulnerabilities that lead to
PNES may help customize many of the interventions with
the goal of providing long-term benecial outcomes. While
the understanding of these vulnerability traits is still at an
early stage,
8
these traits may be key ingredients that need to
be recognized and addressed for a durable, positive outcome
in therapeutic trials and actual practice. Additionally, the role
of the therapeutic relationship cannot be underestimated, as
it may provide the basis for further adaptive development of
emotional expression and identity.
72
Although a case series and therefore not included in the
authors earlier analysis, Rusch et al
11
reported on 26 PNES
adults who received diverse psychotherapeutic interventions
of varying duration based on the symptom pattern underlying
their PNES presentation. All subjects except one experienced
either cessation or improvement of their events. Treatment
was not delivered in a standardized fashion. This article is
mentioned because, although not a standardized interven-
tion, it does capture the essence of the heterogeneous patient
population that PNES patients are, and it demonstrates how,
even with individualized treatment, follow-up data can be
prospectively tracked.
Evaluation of structured therapies such as CBT, psycho-
dynamic therapies and group interventions, and serotoner-
gic antidepressants in larger, randomized, controlled trials
are necessary to establish solid guidelines for treatment.
Event induction through hypnosis has been evaluated to
help discriminate between epileptic seizures and PNES,
73,74

creating interest in hypnotherapy as a potentially effective
intervention. Hypnotherapy was studied in conversion, but
not in PNES-only samples in a rigorous manner, limiting
comparison with the interventions mentioned earlier.
22,23

Additionally, other psychotherapeutic approaches such as
mindfulness-based interventions, EMDR, and sensorimotor
therapy have not been systematically studied and may be
well suited for PNES.
Mindfulness-based interventions are rooted in the con-
cept of mindfulness, paying attention in a particular way:
on purpose, in the present moment and non-judgmentally.
75

Mindfulness has been articulated in specic psychothera-
peutic approaches, such as acceptance and commitment
therapy,
76
dialectical behavioral therapy,
77
mindfulness-based
stress reduction,
75
and mindfulness-based cognitive therapy.
78

The application of mindfulness practice can lead to a shift
in perspective, termed reperceiving, which becomes an
overarching mechanism of action under which more direct
mechanisms, can lead to change and positive outcomes.
79

The emphasis of mindfulness-based interventions on inten-
tional and nonjudgmental attention in the present moment,
followed by an acceptance stance and behavioral choice
based on high-value roles, could help conversion and dis-
sociation patients develop new strategies to eventually
replace their maladaptive ones dictated by their vulner-
ability traits.
80
Sensorimotor therapy has been specically developed
for the treatment of trauma and dissociation. The goal of
sensorimotor therapy is to help the individual process his or
her traumatic experience within a state of optimal arousal,
instead of the usually displayed hypearoused (ie, reexperi-
encing, hypervigilance) or hypoaroused (ie, dissociation,
freezing response) states.
81
Given the high prevalence of
traumatic experiences and also the identied hypervigilance
82

and avoidance tendencies in PNES subjects,
83
this kind of
treatment may hold some promise for at least a subset of
patients.
EMDR has shown results comparable with those of CBT
in the treatment of PTSD, and its proposed mechanism of
action involves processing of trauma memories with new,
positive information, separating the arousal associated with
these memories. This is achieved by creating a vivid image
of the traumatic memory while the patient is led through eye
movements and other tactile stimulations.
36
The creation of
a new mechanism to process these memories without the
associated arousal may also be tting to PNES patients,
especially considering the high prevalence of PTSD in this
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population. Although no rigorous studies were conducted in
PNES, a case series of three subjects with PNES and PTSD
rendered event remission, with this event remission being
sustained for 1218 months.
84
Similarly, as more is learned about the underlying
neurocircuitry dysfunction in PNES,
85
effective treatments
may be strengthened by neuromodulatory interventions.
Conclusion
This review presented the current state in the treatment of
PNES, including limitations and difculties in conducting
clinical trials in this population and a proposed model for
diagnosis presentation. A review of the most recent medical
literature was provided with a detailed description of those
studies with the scientically strongest evidence of efcacy.
Finally, concerns regarding the delay in PNES treatment
development and some practical ideas on how to create
an infrastructure for successful treatment outcomes were
discussed.
CBT and the antidepressant sertraline were evaluated
in pilot double-blind, randomized, controlled trials. Other
interventions evaluated in uncontrolled trials include aug-
mented psychodynamic interpersonal psychotherapy, group
psychodynamic psychotherapy, group psychoeducation and
the antidepressant venlafaxine. These ineterventions all
seem promising, but require further investigation in larger
samples and/or with a more rigorous methodology. Suc-
cessful outcomes in clinical practice will be dependent on
adaptation and exible delivery of these interventions.
Disclosure
The author reports no conicts of interest in this work.
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